JC-1608, 02/18 Temporary Physical Custody Request (Chapter 48) Chapter 48, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Temporary Physical Custody Request (Chapter 48) Case No. Referring Agency Case Number Intake Case Number Requesting Agency Complete C Name [Last, First, Middle] African American Asian or Pacific Islander American Indian or Alaskan Native Hispanic Caucasian Unknown Other Date of Birth Male Female If American Indian or Alaskan Native, list tribe: If an Indian child, use the Indian Child Welfare Act version (IW - 1608 ) form . Telephone Number Why was child/expec tant mother taken into custody? (24724748.19, 48.193 or 48.195 , Wis. Stats. ) Warrant/capias Order by judge Runaway Relinquishment Child suffering from illness, injury or other danger Violation of terms of court - ordered supervision Violation of conditions of temporary custody order Serious health risk to unborn child County of Residence Parent 1 's Name and Address Legal Status: Birth Adjudicated/Adoptive Presum ed Alleged Unknown Date of Birth Home Telephone Number Work Telephone Number Parent 2 's Name and Address Legal Status: Birth Adjudicated/Adoptive Presumed Alleged Unknown Date of Birth Home Telephone Number Work Telephone Number Legal Guardian's Name and Address Date of Birth Home Telephone Number Work Telephone Nu mber Date and Time Taken Into Custody Taken Into Custody By Agency The parents notified by referring party? Yes [Date and Time] No Additional information on notice: Why was child/ expectant mother not released ? Supporting facts of reason why child/expectant mother was taken into physical custody ( 24748.20(3), Wis. Stats.) : See attachment (JC - 1609 Temporary Physical Custody Request Supplement) Copy provided to child/expectant mother, if age 12 or over: Yes No Intake Worker Complete Was child (12 years or older) or expectant mother notified of right to counsel? (24748.20(7)(a) or 24748.203(6)(a) , Wis. Stats. ) Yes No Were notice of custody decision and hearing rights provided? (24748.20(8) , Wis. Stats. ) Parent 1 : Yes, Date and Time: No Parent 2 : Yes, Date and Time: No Child (12 years or older) or expectant mother : Yes, Date and Time: No If no, what ongoing efforts have been made to notify? American LegalNet, Inc. www.FormsWorkFlow.com JC-1608, 02/18 Temporary Physical Custody Request (Chapter 48) Chapter 48, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 Jurisdictional Basis : 1. No Jurisdiction. 2. CHIPS: 247 48.13 3. UCHIPS: 24748.133 Custody Criteria: (247 48 .205 , Wis. Stats. ) 1. Child/Expectant mother will: cause injury to self. be subject to injury by others. run away or be taken away so as to be unavailable for further court proceedings. cause serious health risk to unborn child ( UCHIPS only ). 2. Parent, guardian, legal custodian or other responsible adult is: neglecting refusing unable unavailable to pr ovide adequate supervision and care. Intake Worker Complete Placement Decision: 1. Child/Expectant Mother released. 2. Nonsecure custody: (24748.207 , Wis. Stats. ) a. At the home of a parent. relative. guardian. person not a relative. b. At licensed foster home, treatment foster home, or group home. c. At non - secure facility operated by a licensed child welfare agency. d. At licensed private or public shelter care facility (including holdover room). e. At hospital or physician's office if the child/expectant mother is believed to be suffering from a serious physical condition which requir es either prompt diagnosis or prompt treatment. f. At licensed treatment facility approved by the county as the child/expectant mother is believed to have a mental illness or developmental disability or to be drug dependent and exhibits conduct that constitutes a substantial probability of physical harm to the child/expectant mother or to others, or a very substantial probability of physical impairment or inju ry to the child/expectant mother exists due to the impaired judgment of the child/expectant mother. g. At approved public treatment facility for emergency treatment as the child /expectant mother is believed to be an i ntoxicated person who has threatened, attempted or inflicted physical harm on himself or herself or on another and is likely to inflict such physical harm unless committed, or is incapacitated by alcohol. h. i. At a licensed community - based residential facility ( UCHIPS only ). j. At home of friend of the adult expectant mother ( UCHIPS only ). 3. Secure custody because: (24748.208 , Wis. Stats. ) a. A protective order has been issued and the child consents in wri ting to the placement. b. Child has run away or committed a delinquent act while in nonsecure custody. 4. This is a secure custody placement in a jail because: (24748.209 , Wis. Stats. ) a. No other approved juvenile detention facility is available. b. Child is a substantial risk of physical harm to ot hers in a juvenile detention facility. Placement in the home is contrary to the welfare of the child/expectant mother, due to: See attachment (JC - 1609 Temporary Physical Custody Request Supplement) Efforts made to prevent removal and return the child safely to the home include: See attachment (JC - 1609 Tem porary Physical Custody Request Supplement) Name of Placement Not disclosed to parent due to imminent danger Address Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com JC-1608, 02/18 Temporary Physical Custody Request (Chapter 48) Chapter 48, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 Special precautions/information concerning child/ expectant mother/family Signature of Intake Worker Date and Time Custody Authorized Date and Time of Custody Hearing Date and Time of Release American LegalNet, Inc. www.FormsWorkFlow.com